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Abstract

Background

Healthy children achieve better educational outcomes which, in turn, are associated
with improved health later in life. The World Health Organization’s Health Promoting
Schools (HPS) framework is a holistic approach to promoting health and educational
attainment in school. The effectiveness of this approach has not yet been rigorously
reviewed.

Methods

We searched 20 health, education and social science databases, and trials registries
and relevant websites in 2011 and 2013.

We included cluster randomised controlled trials. Participants were children and young
people aged four to 18 years attending schools/colleges. HPS interventions had to
include the following three elements: input into the curriculum; changes to the school’s
ethos or environment; and engagement with families and/or local communities.

Two reviewers identified relevant trials, extracted data and assessed risk of bias.
We grouped studies according to the health topic(s) targeted. Where data permitted,
we performed random-effects meta-analyses.

Results

We identified 67 eligible trials tackling a range of health issues. Few studies included
any academic/attendance outcomes. We found positive average intervention effects for:
body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake,
tobacco use, and being bullied. Intervention effects were generally small. On average
across studies, we found little evidence of effectiveness for zBMI (BMI, standardized
for age and gender), and no evidence for fat intake, alcohol use, drug use, mental
health, violence and bullying others. It was not possible to meta-analyse data on
other health outcomes due to lack of data. Methodological limitations were identified
including reliance on self-reported data, lack of long-term follow-up, and high attrition
rates.

Conclusion

This Cochrane review has found the WHO HPS framework is effective at improving some
aspects of student health. The effects are small but potentially important at a population
level.

The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

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